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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> Nov 23,2010 <br /> 8wceo meas ren FNyy� SITE MITIGATION$ LOP <br /> `�'°f CI UNIT IV <br /> OWNER FILE:Conte[�rNEFottot1It-ROPERTYOWN ER/NFORMgnoN• CorgaIOWNERcueRrvnroer,Ew ENDS <br /> P <br /> a NAME NA <br /> NA ( � 210-283-2000 <br /> Fist Nr Loaf PNomeNutaet <br /> Tesoro Companies Inc E,MMLAWRM <br /> ddress, <br /> 3450 South 344th Way <br /> Aubum sT^M ZanAddreus CRy <br /> SWb ZIP <br /> CARPORAMMQ INDNIDUAL❑ PARMEashvpL1 <br /> FFDAGENCY❑ <br /> Sun MrTIDA•r1OIJ_ENNRONMRNTAL AfflffMENT_VDLUNTA,IY CLEANU►_WATUR QUALITY_MW PIPRUNK INVEfTIOATTON_LDP <br /> FpOLLIT'IDf Inv# ACCOUNTID PRMRO% AsslcN®EMPwym LfgDAGErcY:EHD_RWgCB_DTSC_EP,g_ <br /> FACILITYFII.E COMPLETEAAEMLLOW/NG BUSINESS/FACILITY/SITE&FoRmAri <br /> Is this a NEw Business LOCATION nOtpraviously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes <br /> ❑ No ❑ <br /> Is thisan E%ISTNG Business LDOATION bate NbwTWE ofrng111altadgusiness7 <br /> auslNesvFACRmreIreNAMe Tesoro Fuel Terminal Yet 13 No <br /> Sm ADDAM <br /> 3003 Navy Drive Sun$ BustaimpHoNE <br /> Cm <br /> 209-466-8800 <br /> Stockton STATE ZIP <br /> CA 95206 <br /> BO DOFSUPEaY"RDIETTUOT LochrONCODE KEY1 <br /> KEYt <br /> Mallksg Address, VWAeore <br /> AdenUon:orCate Of(tPptkrtelJ <br /> MI Addnam CILy <br /> STATE ZIP <br /> SICCODE ApNf OOMMENi: <br /> THIRD PARTY PILLINDINFO Complete if BlOing Partys different from Property Owner ot-FoollitY OpOrEtor ident6edabove. <br /> 13"thas NAM, <br /> 8tantec Consulting Corporation Todd Brown Attention:arca a Of/opoa a,9 <br /> MaRlne Address <br /> 3017 Kiloore Road 5to 100 PtDME <br /> 916-861-04 0 —ll <br /> Cm• Rancho Cordova CA 956706150 STATE <br /> Zia, <br /> 6CG�o[AtTn for e and charges OWNER FACY/BUSINESS THIRD PARTY BILLING <br /> B N tN-Ahb 'OMP A DG ^+•*v 1,the umkoUgned AppHeam,eerI that I am the over, <br /> AnnRITopemmy orAmamiad.iann of Wk Bmineq and 7 acknowledge that ne➢eavnFLer, <br /> PA'.v.rnrs,B+roaravE+TCxaaees and/or Hol'.vT'"He .l.IwmMd with this npenNnn wlll be hilled Is me at toe address Identified abnw•as Me A[ A <br /> aU infurmados provldrd on Chir appentloo h Irvr aad correct;esd that aN ngvlered artivkiea wW be performed le aaordaoa w9tb dl appdcable SAN J OCo <br /> Cpun•Iy OrdSoasce Codes vd/or <br /> Standards and STAT-•nd/ar PIMg L taws and Regoiebnv As the Undersigned owner,operetoy or nganl of the property Imaed at the about leeilNr/N addren,l bereby d1smce the r, of <br /> pro id d all results nod environmesdl n4essmenf ioformatlon ro SAN JOAQUIN Colt IRO ENTAL HEALTH DEPARTMENT'as soon n N 1,avWl.bk aad at Me same dme It is <br /> m,and to meormlr nviomovr. / / <br /> APPLICANT NAME PtEunEPaNr) / /ed�i' <br /> TITLE <br /> TAX 10 <br /> ffjDate lwmuntlrq oRba PropaeHrR CnmpNlade <br /> SITEpW <br /> AMOUIn PAIp DATEOF PAYMB,T PAyMENTTYPE RECEIPT[ RfCENEO BY WORRPUNPE <br />